Starting the conversation about code status and goals of care in the ED matters. Not infrequently, we’re caring for patients with life-threatening injuries, advanced age, or serious medical comorbidities. Our training prepares us to stabilize these acute conditions, but in doing so, we often establish a trajectory for the rest of the hospital stay—one that profoundly impacts both the patient and their family. Having these conversations during their time in our care should be a routine part of emergency medicine.
There are plenty of reasons we hesitate to start these discussions—time constraints, the hope that it’s already been addressed by a PCP, cultural or personal discomfort with death or a sense that a patient’s death reflects professional failure. But when we’re treating critically ill patients or those with significant comorbidities, it’s essential to ask: Are aggressive measures in line with this patient’s goals of care?
We can easily become fixated on stabilizing the immediate crisis, but the choices we make in the ED can commit a patient to invasive interventions that may not align with their values. Just because we can perform an intervention doesn’t always mean we should.
If a patient is critically ill and nearing intubation, peri-respiratory failure, or peri-arrest, someone needs to talk with them—or their family—about their wishes. Similarly, patients with advanced chronic illnesses and a poor clinical trajectory deserve a conversation about the goals of care.
Think about the admitting service. If you know that the team won’t initiate these conversations, take the opportunity to have them in the ED and document it. If you’re treating a chronically or terminally ill patient with multiple hospital visits and little benefit, this might be your window to ask about their long-term goals. Maybe they’ve never been told about palliative or hospice services. Maybe no one’s taken the time to offer an alternative to the revolving door of admissions.
Understand what matters most to the patient.
Ask open-ended questions like:
This helps clarify what they value and whether interventions like CPR align with those values.
Seriously. Just sitting at eye level makes patients and families feel like you’ve spent more time with them and builds a sense of compassion and trust.
Patients may assume that because you brought it up, you know something they don’t. Reassure them this is standard care. Try:
“We talk to all of our patients about their wishes around CPR and ventilators—even when they’re here for something like a broken finger.”
If you anticipate a longer or more emotional conversation, ask for permission to continue or offer to include a family member.
“I’d like to talk about whether CPR makes sense for you. Is that okay?”
Most people don’t know what “code status” or “goals of care” mean. Use plain terms like CPR or breathing machines. And don’t assume they understand outcomes. In one study, only 7% of elderly patients could correctly define “code status,” and most were overly optimistic about CPR survival rates.
Try something like:
“CPR is a procedure we do when someone has died and their heart has stopped. About 80–90% of the time, it doesn’t work. For patients over 80 or with medical problems, the chances of survival are even lower.”
You have the knowledge and experience—patients appreciate it when you share your perspective. The stats aren’t great:
Those numbers can mean the difference between independent living and needing long-term care.
Taking time for a proper goals-of-care conversation can bring clarity to the patient and family, prevent unnecessary interventions, and reduce the emotional trauma of future care withdrawal decisions. So, talk to your patient. Listen to their story.
Then, when they need it most, you can be their voice and their advocate.